Scenario 2 - Part 1:

A 39-year-old male with a prior history of recurrent stone formation, presents with right-sided flank pain, burning urination and vomiting. On physical examination, there is tenderness over the right lumbar area. The patient had a history of sudden weakness for which he received several shots of Vit-D injection over the last year. His father died because of renal failure.

Review of his lab tests showed the following:

Test

Value

S. Creatinine

1.17 mg/dL

S. Corrected Calcium 

10.5 mg/dL

S. Phosphorus

3.3 mg/dL

25 (OH) Vit D

98 ng/mL

iPTH

33 pg/mL

 

  1. Interpret the above laboratory investigations.
  2. Would you recommend any further laboratory investigations.

31 Comments

  • Radwa Ellisy


    this is a case of hypervitaminosis D with mild hypercalcemia and normal phosphorus and PTH level, mostly due to large doses received in the last year.
    may be complicated by stone formation causing the flank pain.

    • further lab:

    given the data of positive family history with the presence of stone- 24-hour urinary( calcium, oxalate, citrate)

    • abdominal US, CT KUB
  • Marwa Alm


    Labs show hyper-vitaminosis D, Ca upper normal
    Further investigations are needed: complete metabolic panel, urine analysis, urine c/s, pelviabdominal USG, CT KUB, if no stones were detected: 24hrs urinary profile.

  • Khaldon Rashed Ahmed Moqbil


    Vid d intoxication with hypercalcim

    Urinalysis +C/S
    Metabolic screen 
    Stone analysis 
    Abdomen U/S, CT

  • Areij Alotaibi


    1- hypercalcemia with high vitamin D level

    2- kub , Us

  • Asma Aljaberi


    1. Interpret the above laboratory investigations.
    2. Mild hypercalcemia with low normal ph level and normal iPTH. Given the patient’s hx of flank pain, recurrent renal stones, and lumbar spine tenderness, primary hyperparathyroidism is highly in my DDx list. Due to hyperparathyroidism, the conversion of 25 OD vit D3 to 1-25 OD vit D increased, mistakenly interpreted as vit D deficiency. As a result, she received multiple Vit D injections. That led to highl 25 OD vit D on current labs.
    3. Would you recommend any further laboratory investigations.
    • 24 hrs urine Ca, Cr, Na
    • Urine analysis
    • 1-25 OH vit D
    • KUB/CT abdomen
    • Spine XRay
  • Muhammad Soobadar


    hypercalcaemia due hypervitaminosis
    hypercalcaemia causing stone

    Urine dip/msu/ urine culture /non contrast CTKUB 24 hr urine volume,ph citrate,oxalate calcium uric acid ,cysteine due to FH

  • Mohamed Abdulahi Hassan


    interpret the above laboratory investigations.
    high vitamin level other lab investigation is with in normal range
    the flank pain could be due to renal stones combined with vit D intoxication …
    taking too much vitamin d can cause renal stones
    further lab investigation .. cbc , renal function test, urinalysis ,,KUB ct

  • Mark Nagy Zaki Amin Mark


    1- upper normal calcium level with vit D intoxication
    other labs are within normal range
    2-urine analysis , CBC, Abd US, spiral CT abd and pelvis , 24h urinary calcium excretion

  • Rania Mahmoud


    Interpret the above laboratory investigations.Patient has high level of vit D and calcium due to recurrent stone formation

    Would you recommend any further laboratory investigations.Abdomin/pelvis U/SUrine analysis and urine cultureKUB x rayCT KUB24 hour urinary (volume, calcium, oxalate,citrate, uric acid, and creatinine)RFTCBC

  • Rabab Elrefaey


    Thank you dear colleagues for your great contributions.
    Here are the explanation for this part.
    
    A. Interpret the above laboratory investigations.

    The patient presented according to his laboratory investigations by high levels of vitamin D and  hypercalcemia. Mostly these abnormalities are the cause of the patient’s complaint and recurrent renal stone formation.

    B. Would you recommend any further laboratory investigations.

    The patient presented with flank pain and burning urination. So, it is highly suspected for either nephrolithiasis or urinary tract infection. 

    Pelviabdominal ultrasound to comment especially on the urinary tract, urine analysis and urine culture are also important. Complete blood count is helpful. Spiral CT abdomen may be needed to confirm the presence of renal stones. Since the patient has recurrent history of renal stones and positive family history of renal disease, a metabolic panel is needed including 24 hour urinary  (volume, calcium, oxalate,citrate, uric acid, and creatinine) and serum uric acid.

  • Mahmoud Elsheikh


    Normal kidney function, with hypercalcemia and hypervitaminosis (D). For urinary calcium. TSH. Serum K, mg. ALP. CT-KUB

  • Asmaa Salih KHUDHUR


    Interpret the above laboratory investigations.

    upper normal serum creatinine.
    hypervitaminosis D.
    mild hypercalcemia.
    normal serum PTH.

    Would you recommend any further laboratory investigations.
    urinalysis 
    Urine C/S
    Metabolic screen 
    Stone analysis 
    Abdomen U/S, CT
    Abdomen KUB

  • Rabab ALaa Eldin keshk Rabab


    1-Lab interpretation ca at upper level
    Vit d level was high near to toxic level normal
    2-other lab recommended exclude mm via spep serum mg work up of renal stone 24 hr ca ,mg, oxalate and po4 and uric acid

  • Riaan Flooks


    1. Interpretation
    • Elevated Vitamin D
    • Hypercalcemia, with relatively normal PTH
    1. Work-Up:
    • Urine MC+S and urine dipsticks
    • Abdominal sonar and an uncontrasted CT renal tract
    • Renal stone work-up – 24hr urine collection for calcium , oxalate ,citrate, phosphate and uric acid
    • s-Uric Acid
  • Ahmed Altalawy


    1.Interpret the above laboratory investigations.
    Hypervitamosis D, with mild hypercalcemia

    2.Would you recommend any further laboratory investigations.
    U/S KUB, CT Kidney
    urine analysis and culture
    S.uric acid
    24-hour urine for stone panel and (calcium /creatinine)
    serum bicarbonate

  • Abdulrahman Almutawakel


    THIS PATIENT HAS STAGE 2 CKD BASED ON EGDR , HIS PAIN MOSTLIKLY URETRIC COLIC WITH UTI OR LOWER URETRIC STONE NEEDS FOR URGENT ULTRASOUND OR NONCONTRAST CT SCAN , URINE ANALYSIS , URINE ELECTROLYTES ALSO

  • HASSAN ALYAMMAHI


    • Hypervitamosis D, with mild hypercalcemia
    • 1,25(OH)vitD, urinary Ca / Ca:Creatinine, urinary Oxalate, Phosphate and urate, US KUB
  • Hagar Ali


    1. hypercalcemia with high level of VD
    2. CT KUB-24 h urinary ca -s.UA -s.mg
  • Israa Hammoodi


    1. Upper normal s. Creatinine , high level of vitamin D level
    2. S. Na, K., Mg , s. Uric acid
    BGA
    US of renal system or CT abdomen
    24 hrs Urine Ca, phosphorous, uric acid, oxalate, citrate, cysteine, creatinine

  • KAMAL ELGORASHI


    The above lab result
    Shows normal kidney function, with hypercalcemia and hypervitaminosis (D).
    Further recommended investigation

    • 24 urinary calcium.
    • TSH
    • Serum K.
    • Serum Mg.
    • ALP
    • CT-KUB.
  • Amna Kununa


    Interpret the above laboratory investigations.

    • moderate hypercalcemia
    • normal iPTH
    • high VitD (A “risk” of vitamin D toxicity is defined as a vitD level >100 ng/mL in adults ingesting substantial amounts of calcium).

    Likely he has symptomatic kidney stones vs pyelonephritis

    Would you recommend any further laboratory investigations.

    • Basic metabolic panel to assess kidney function
    • Urinalysis to evaluate for hematuria and signs of urinary tract infection, keep in mind sterile pyuria.
    • image: u/s kidneys and bladder and CT-KUB
    • stone analysis if he pass stone
    • 24-hour urine collections: at least two 24-hour urine collections should be obtained in the outpatient setting, with the patient following their usual diet, fluid intake, and physical activity.

    plain: for volume, pH,Na,K,citrate,urate,and Cysteine level
    acid: for volume, Ca,Pi and oxalate level

  • Nour Al Natout


    1.there is excess of vitamin D and mild hypercalcemia
    2Ultrasound of kidney and maybe CT to exclude nephrolithiasis
    Urinary status should be analysed,and 24 Urin for Calcium , oxalate ,citrate, phosphate and uric acid.

  • Mahmud ISLAM


    Mild hypercalcemia with a high vitamin D level. Vitamin d overdose seems to be the cause. Nephrocalcinosis and urinary stones are frequent. We need urinary CT or US to confirm and decide about the need of emergent urologic intervention

  • Weam El Nazer


    1. Interpret the above laboratory investigations.

    mild hypercalcemia, mild hypophosphatemia, normal PTH, high Vit-D, stone former with the manifestation of acute renal colic most likely second to stone

    1. Would you recommend any further laboratory investigations?

    U/S KUB, CT Kidney
    urine analysis and culture
    S.uric acid
    24-hour urine for stone panel and (calcium /creatinine)
    serum bicarbonate

  • Ben Lomatayo


    Interpret the above laboratory investigations.

    • Clinically suspected UTI or infected renal stone
    • eGFR ~81.8 by CKD-EPI, with history of recurrent stone it could be repeated AKI or AKD or even CKD 2G. We need to check GFR again after 3 months
    • Ca at higher side, vitamin D level at higher side
    • Normal phosphate & PTH
    • Father died of renal disease may point toward familial or genetic forms of CKD

    Would you recommend any further laboratory investigations.

    1. Urinalysis
    2. Urine culture
    3. Urine PH
    4. 24 h urine for metabolic stone assessments
    5. Acid base status: blood PH & serum HCO3
    6. Serum electrolytes including K, Na & Mg
    7. Uric acid levels
    8. U/S KUB
    9. Plain CT KUB
  • Rihab Elidrisi


    This patient lab showed hypervitaminosis D with mild hypercalcemia
    she had normal PTH and PO4 level

    will need to have Us abdomen to see if she is passing a stone.

  • Ashraf Ahmed Mahmoud


    Interpret the above laboratory investigations.
    

    • hypervitaminosis D.
    • normal PTH and phosphate

    Would you recommend any further laboratory investigations.

    • urine analysis.
    • Abdomen US
    • X-ray KUB
    • 24-hour urinary , citrate, oxalate, and Ca.
    • serum uric acid.
  • Emad mohamed mokbel Salem


    1-mild hypercalcemia with normal serum po4 and PTH ,high 25(OH )D3
    2-ask for
    24 hour collection of calcium ,uric acid ,oxalalte )
    serum K and hco3 to r/o RTA
    uric acid
    kidney uss

  • MOHAMMED HAJI HASSAN


    Interpret the above laboratory investigations.

    High vit D level- normal PTH and phosphate
    patients complaint is consistent with renal stone due to Vit-D injection

    2. Would you recommend any further laboratory investigations?

    Urinalysis
    Uric Acid Level
    24-hr urinary calcium
    Renal ultrasound or abdominal CT
    Serum alkaline phosphatase

  • Elsayed Ghorab


    39y/o/m c/o rt. flank pain w dysuria , vomiting
    hist. of renal calculi , hist. of shot inj. vit.D ,hist.of sudden weakness and family hist. of father died from renal failure
    lab. revealed
    hyper vit. D , hyper calcemia
    normal scr. and pi . and iPTH
    RECOMMENDATION
    f/u renal function and abg -cbc urine analysis , 24 h protein in urine and urine c/s
    imaging kidney sonar and ct

  • Ibrahim Omar


    Interpret the above laboratory investigations.

    • upper normal serum creatinine.
    • hypervitaminosis D.
    • mild hypercalcemia.
    • normal serum PTH.

    Would you recommend any further laboratory investigations.

    • urine analysis.
    • metabolic profile for stone formers including 24-hour urinary calcium, citrate, oxalate, and urate.
    • serum uric acid.
    • Abdomen US.

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